MEDICARE: DR. LISA CAROL OVERTON D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	SC004492L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2063808000	OTHER	PA	IBC 10 DIGIT HMO ID
3	10741	OTHER	PA	ELDER HEALTH ID
4	5403600001	OTHER	PA	DMERC SUPPLIER ID
5	001372137	OTHER	PA	HIGHMARK BLUE SHIELD ID

General Provider Information

NPI Number	:	1619923190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA CAROL OVERTON D.P.M.

Provider Business Mailing Address
First Line	:	1940 E WALNUT LN
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-1312
Country	:	US
Telephone Number	:	215-548-2113
Fax Number	:	215-548-3009

Provider Business Practice Location Address
First Line	:	1940 E WALNUT LN
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-1312
Country	:	US
Telephone Number	:	215-548-2113
Fax Number	:	215-548-3009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	07/08/2011

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